Changes in Psychological Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

Investigations into complementary and alternative medicine (CAM) approaches to address stress, depression, and anxiety of those experiencing chronic pain are rare. The objective of this pilot study was to assess the value of a structured massage therapy program, with a focus on myofascial trigger points, on psychological measures associated with tension-type headache. Participants were enrolled in an open-label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week periods) and a follow-up phase. Eighteen subjects with episodic or chronic tension-type headache were enrolled and evaluated at 3-week intervals using the State-Trait Anxiety Inventory, Beck Depression Inventory, and the Perceived Stress Scale. The Daily Stress Inventory was administered over 7-day periods during baseline and the final week of massage. Twice weekly, 45-minute massage therapy sessions commenced following the baseline phase and continued for 6 weeks. A significant improvement in all psychological measures was detected over the timeframe of the study. Post hoc evaluation indicated improvement over baseline for depression and trait anxiety following 6 weeks of massage, but not 3 weeks. A reduction in the number of events deemed stressful as well as their respective impact was detected. This pilot study provides evidence for reduction of affective distress in a chronic pain population, suggesting the need for more rigorously controlled studies using massage therapy to address psychological measures associated with TTH.KEYWORDS: Beck Depression Inventory, Complementary and Alternative Medicine, Daily Stress Inventory, Myofascial Pain, State-Trait Anxiety InventoryTension-type headache (TTH) is a 15 days per month and the chronic form dull aching headache that affects a 15 or more days per month¹. The epilarge percentage of the population sodic form of TTH affects between 20to varying degrees; it frequently resolves 42% of the population while the chronic with time or over-the-counter analgesics. form affects 2.5-3%^2,3. The authors of a however, for some individuals, the regu-recent review article concluded that larity of headache persists to a clinical worldwide disability attributable to condition that is recognized as either epi-headache is greater for TTH than other sodic or chronic, the difference based classifications including migraine head-primarily on the frequency of attack with ache⁴. The personal burden associated the episodic form occurring fewer than with these clinical forms of TTH can be substantial as it encompasses physical suffering alongside the personal economic effect from lost work days, which in turn perpetuate psychological symptoms such as stress, anxiety, and depression. Yet while TTH is the most prevalent form of headache and has a considerable impact on quality of life, treatment avenues have been under-investigated⁵. Moreover, due to the pervasive nature of TTH, pain measures alone that are typically used in the current literature provide incomplete information about the impact of headache on these associated psychological aspects.On average, perceived stress is higher in individuals who report chronic daily headache than in a healthy population⁶. Although recurrent TTH sufferers have similar physiological responses to laboratory stressors, they report a greater number of everyday stresses or daily “hassles” than do matched non-headache control subjects^7,8. Furthermore, stressful events are appraised as more stressful for recurrent TTH sufferers than for headache-free subjects⁷. Stress is also the most frequent headache trigger with 88% of patients from the general population in urban and rural areas reporting this variable as a cause for ensuing headache⁹. Finally, stress has been noted to exacerbate headache symptoms; and minor everyday stressors, rather than major life events, have been tagged as a contributor to maintaining or prolonging existing headache¹⁰. Thus, stress, particularly as a result of minor everyday frustrations, is an important area of investigation in relation to headache.In addition to stress, elevated anxiety and depression are commonly reported among those with headache¹¹. Again, the prevalence of anxiety and depression is greater in those with TTH than in a non-headache population¹¹, with chronicity of headache associated with increased affective distress¹². In adult patients with chronic TTH, major depression has been reported in 59%, with 25% experiencing an anxiety disorder¹³. The effect is not limited to adults; a study involving children and young adults with TTH reported that 50% suffer from one or more psychiatric disorders, with anxiety and depression the two most commonly cited¹⁴. In a study examining stress, depression, and anxiety in primary headache patients, depression and anxiety were found to frequently co-exist in the same subject¹⁵. Affective distress, in addition to pain, has been described as an important component to address in the treatment of TTH patients⁹.Complementary and alternative therapies have been used as corrective treatments for ailments including chronic pain and psychopathological conditions¹⁶. Of patients visiting a headache clinic, 40% use one or more complementary and alternative medicine modalities to reduce pain associated with chronic TTH¹⁷, with 26.7% using massage as a coping strategy for the pain¹⁸. Additional reference to the use of massage has been noted in several studies involving TTH patients. Scalp massage is cited as a primary self-treatment used by TTH sufferers¹⁹, and self-massage of cranial musculature is regularly employed by 25% of TTH patients as a quick means to reduce pain although the immediate benefit was found to wane within 5 minutes of stopping the maneuver²⁰. Although only a few pilot studies have directly investigated the effect of massage therapy on TTH, the findings have been positive for reducing headache frequency and intensity^21,22.In addition to its use for reducing headache pain, massage therapy has also been suggested as a means for reducing psychological distress. Reductions in measures of stress, anxiety, and depression have been noted in healthy populations^23–25 as well as those experiencing chronic pain^26,27. healthcare professionals also rank massage therapy as effective for stress and anxiety reduction²⁸. The effect of massage therapy on psychological affect in a TTH population has not been specifically studied. Subsequently, the objective of this study was to evaluate a replicable massage therapy treatment directed at cervical and cranial musculature on psychological measures including stress, anxiety, and depression in subjects with TTH.